In-Home Supports Waiver - Certificate of Competency

In-Home Supports Waiver
06IS037E (DDS-37) v.3 08/02/2012 Page 1 of 2
Certificate of Competency
Name of habilitation training specialist (HTS)/direct support staff
I want the above named person employed as HTS/direct support staff, and I certify the above named
person has demonstrated competency in the care of
prior to employment.
I am assuring the above named person has been trained and has demonstrated the skills necessary
to meet the service recipient’s needs. First aid, cardio-pulmonary resuscitation (CPR), and individualspecific
training identified in the service recipient's Individual Plan are required. Medication
administration training (MAT) is required when staff is responsible for administering medication.
Neither OKDHS nor the provider agency will be held liable in the event of harm to
while in the care of the above named person
attributable to lack of training or for any other reason.
,
Print service recipient or legal guardian name
Signature of service recipient or legal guardian Date
This certificate is valid for one year, and may be revoked at any time by providing written notice to
the Developmental Disabilities Services Division (DDSD) case manager and provider agency.
This certificate is required when a service recipient, legal guardian, or parent(s) of a minor service
recipient requests to exempt a proposed HTS/direct support staff from the additional OKDHS DDSD
required training, per OAC 340:100-3-38.5, or when the choice is made to self-direct HTS. The
proposed support staff must have demonstrated competency in meeting the service recipient's
service requirements prior to employment. When the service recipient is an adult without a legal
guardian, Form 06IS038E, In-Home Supports Waiver – Family Member's Statement, is required as
training requirements are not waived without concurrence of a parent or family member closest to the
service recipient. OKDHS may withdraw this training exemption at any time.
Certification is available for service recipients receiving services through In Home Supports
Waiver for Children or In-Home Supports Waiver for Adults and is valid only for the named
service recipient and named HTS/direct support staff.
The DDSD case manager provides the certificate to the service recipient, legal guardian,
or parent(s) of a minor service recipient when the request is made for a friend, neighbor,
family member, or other person to provide services who has already completed first aid,
CPR, individual-specific training and if applicable, MAT, and demonstrated competency in
meeting the service recipient's needs.
06IS037E (DDS-37) v.3 08/02/2012 Page 2 of 2
Provider agency HTS. Proposed staff presents original certificate to the selected provider
agency. The employing provider agency retains original certificate during employment and
returns the certificate to staff upon termination of employment. The DDSD case manager
retains a copy.
Self-directed HTS (SD-HTS). The employer of record maintains the certificate during
employment and returns the certificate to staff upon termination of employment. The
DDSD case manager retains a copy.
The provider agency or employer of record may require training not included in this
exemption.
When a SD-HTS completes OKDHS DDSD required training per OAC 340:100-3-38.5,
copies of the training record are maintained by the employer of record.

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In-Home Supports Waiver
06IS037E (DDS-37) v.3 08/02/2012 Page 1 of 2
Certificate of Competency
Name of habilitation training specialist (HTS)/direct support staff
I want the above named person employed as HTS/direct support staff, and I certify the above named
person has demonstrated competency in the care of
prior to employment.
I am assuring the above named person has been trained and has demonstrated the skills necessary
to meet the service recipient’s needs. First aid, cardio-pulmonary resuscitation (CPR), and individualspecific
training identified in the service recipient's Individual Plan are required. Medication
administration training (MAT) is required when staff is responsible for administering medication.
Neither OKDHS nor the provider agency will be held liable in the event of harm to
while in the care of the above named person
attributable to lack of training or for any other reason.
,
Print service recipient or legal guardian name
Signature of service recipient or legal guardian Date
This certificate is valid for one year, and may be revoked at any time by providing written notice to
the Developmental Disabilities Services Division (DDSD) case manager and provider agency.
This certificate is required when a service recipient, legal guardian, or parent(s) of a minor service
recipient requests to exempt a proposed HTS/direct support staff from the additional OKDHS DDSD
required training, per OAC 340:100-3-38.5, or when the choice is made to self-direct HTS. The
proposed support staff must have demonstrated competency in meeting the service recipient's
service requirements prior to employment. When the service recipient is an adult without a legal
guardian, Form 06IS038E, In-Home Supports Waiver – Family Member's Statement, is required as
training requirements are not waived without concurrence of a parent or family member closest to the
service recipient. OKDHS may withdraw this training exemption at any time.
Certification is available for service recipients receiving services through In Home Supports
Waiver for Children or In-Home Supports Waiver for Adults and is valid only for the named
service recipient and named HTS/direct support staff.
The DDSD case manager provides the certificate to the service recipient, legal guardian,
or parent(s) of a minor service recipient when the request is made for a friend, neighbor,
family member, or other person to provide services who has already completed first aid,
CPR, individual-specific training and if applicable, MAT, and demonstrated competency in
meeting the service recipient's needs.
06IS037E (DDS-37) v.3 08/02/2012 Page 2 of 2
Provider agency HTS. Proposed staff presents original certificate to the selected provider
agency. The employing provider agency retains original certificate during employment and
returns the certificate to staff upon termination of employment. The DDSD case manager
retains a copy.
Self-directed HTS (SD-HTS). The employer of record maintains the certificate during
employment and returns the certificate to staff upon termination of employment. The
DDSD case manager retains a copy.
The provider agency or employer of record may require training not included in this
exemption.
When a SD-HTS completes OKDHS DDSD required training per OAC 340:100-3-38.5,
copies of the training record are maintained by the employer of record.